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' APPLICATION FOR PERMIT (sW SAN JOAQUIN LOCAL HEALTH DISTRICT D �� ( 1601 E. HAZELTON AVE., STOCKTON, CA `+ Telephone (209) 466-6781 J U N 4 1987 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ENVIROMENTAL HEALTH PERMIT/SERVICcS Application is hereby made to the San Joaquin Local H4alth District for permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Jab Address W CA-1- Vkc.w.w.c r (�,�t✓ City. Lot Size pM Owner's Name E nn t).L 6 Cl v Q uO✓44&,N 1L X A' Address 1_ 14 til r- C 1 m XZ Phone /0 W Rkt- G,. sur Contractor Address _ = -1.:.•z•�tycense No:r�� U^1Y3f/� - w+-none - 3 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION •7s"Cee AGRICULTURE WELL oo OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Die, of Wen Casing ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing (_V/C, Sp ectfications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal a �" //��'. �� ' Type of Grout ❑ Irrigation 60�Approx. Depth ❑ Easter Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50) Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Installation will serve: Residence_ Commercial_ Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation taws of Cafrfomia."Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must cal for all required ins actions. C plate drawing on reverse side. Signed X Title: ,"Y��tiec 1�4t I Date: 7 `c' 7 _ T O Application Accepted b ate G — 1"Area �i/ Pk or Grout In ion Date Final Inspection by _ Date 01 1 00, Additional Com ts: l ❑ Stk 486-6781 ❑ Lodi 369-3821 ❑ Manteca 823-7104 ❑ Tracy '4ppOcant- Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2008, Stk., CA 1 FEE AMOUNT DUE AMOUNT REMITTED K INFO CASH RECEIVED BY DATE PERMIT'NO. 3s:ov >